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Autism and Related Insurance Resources

HB1311 was signed by Gov. Jay Nixon on June 10, 2010. The law requires private insurance companies operating in Missouri to provide coverage under group health insurance policies for psychiatric care, psychological care, habilitative or rehabilitative care (including applied behavior analysis (ABA) therapy), therapeutic and pharmacy care to children who have been diagnosed with autism spectrum disorder (ASD). If you have an individual health benefit plan (rather than coverage through your employer), you may add this coverage, however there may be an additional cost. The law also establishes licensure requirements for therapists who provide the ABA therapy to children with ASD.

Frequently asked questions about Missouri's new autism insurance law

When does the autism coverage mandate go into effect?

The new provisions regarding mandated benefits for autism and autism spectrum disorder go into effect for policies that are issued or renewed on or after Jan. 1, 2011. As an example, if you have a health plan that renews each year on June 1, then your policy will reflect the new coverage requirements when it renews on June 1, 2011.

Does the mandate apply only to autism?

No. The new law requires coverage for autism spectrum disorders including autistic disorder, Asperger’s Disorder, Pervasive Developmental Disorder, Rett’s Disorder and Childhood Disintegrative Disorder, as defined in the Diagnostic and Statistical Manual (DSM).

What insurance plans are affected?

The autism coverage mandate applies to:

All small group or large group health insurance plans written in Missouri.

All small group or large group health insurance plans written in other states but insuring Missouri residents, to the extent not already covered by the plan.

All self-insured governmental plans (defined by USC Section 1002(32).

All self-insured group arrangements, to the extent not pre-empted by federal law.

All plans provided through a multiple employer welfare arrangements or other benefit arrangements, to the extent not pre-empted by federal law.

All self-insured school district plans.

For the following types of insurance, the coverage is not automatically included, but must be offered to the insured and dependents:

Individually underwritten health insurance plans.

Individually underwritten association groups.

Other individually underwritten discretionary groups.

The law does not apply to a supplemental insurance policy, including a life care contract, accident-only policy, specified disease policy, hospital policy providing a fixed daily benefit only, Medicare supplement policy, long-term care policy, short-term major medical policy of six months or less duration, or any other supplemental policy, even if such policies are offered on a group plan basis.

In “self-insured” or “self-funded” plans, the employer pays medical claims directly, rather than
purchasing a group insurance policy. In many cases, these employers will hire an insurance company to administer the plan and pay claims for them. However, ultimately, the employer decides on the coverage and pays the claims. Many of these self-insured plans are exempt from state insurance laws, including the new autism law.

What treatments are required under this law?

The new law requires that coverage be provided to individuals with a diagnosis of autism or related autism spectrum disorders for the following types of treatment:

What types of treatment does “psychiatric care” and “psychological care” include?

Psychiatric and psychological care is care provided by a licensed psychiatrist or psychologist, respectively.

What is “habilitative” and “rehabilitative care”?

The law defines “habilitative” and “rehabilitative care” as “professional, counseling, and guidance services and treatment programs, including applied behavior analysis, that are necessary to develop the functioning of an individual.”

The law defines “pharmacy care” as ”medications used to address symptoms of an autism spectrum disorder prescribed by a licensed physician, and any health-related services deemed medically necessary to determine the need or effectiveness of the medications” – but “only to the extent such medications are included” in the health benefit plan covering the individual.

What is applied behavior analysis (ABA)?

Under the new law, ABA is defined as, “the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationships between environment and behavior.” Essentially, this form of therapy uses applied behavior methods to increase a child’s ability to communicate and socialize.

Are there limits or caps on ABA therapy?

Yes. The benefit for ABA therapy is capped at $41,263 per year for children until their 19th birthday. There are no annual limits on the number of visits. The treatment must be prescribed by the child’s physician or psychologist and detailed in a treatment plan that is subject to review at least every six months.
This cap will be adjusted periodically for inflation. You can check back to this page for further information when the cap is adjusted.

Will I have higher deductibles or copayments for this autism or ABA therapy?

No. Under the law, any services provided for the treatment of autism, including ABA therapy, cannot have a greater deductible, coinsurance or copayment than other physical health care services. Other policy provisions that apply to other physical health conditions or treatments may still apply.

Can my insurance company require a pre-authorization or precertification for autism treatments like physical therapy and what is a precertification?

Yes. Pre-authorizations or pre-certifications are formal requests from a provider to an insurance company to review a proposed course of treatment and determine if the treatment is covered under your health insurance plan and is medically necessary. You can know ahead of time if the insurance company does not believe the treatment is covered or medically necessary. While it is not a guarantee of payment, when your provider receives a pre-authorization or pre-certification number,
that is a good indication the claim
will be paid.

Under Missouri law, if an insurance company provides a pre-certification number, it is not allowed to subsequently retract its authorization once the services have been provided. The only exceptions under Missouri law would be if there was fraud or misrepresentation or if the health plan or coverage for the individual terminates before the health service is provided.

My child is receiving a new type of treatment for autism that is not ABA. Does the law specify other types of treatment that are required to be covered?

Occupational therapy, physical therapy, speech therapy and ABA therapy are the only treatments specifically identified in the law. Other treatments will be reviewed for coverage by the insurance company based on the requirements of the law, whether the treatment is medically necessary, and whether the treatment is ordered as a part of the treatment plan that was created by a licensed physician or psychologist.

What if my child has been previously diagnosed as being in the autism spectrum – will the insurance company be able to exclude coverage or deny coverage because it is a pre-existing condition?

No. Insurance companies routinely ask questions about medical history, but this law prohibits insurance companies from denying or refusing to issue health insurance coverage for any individual or their dependent because of an autism spectrum diagnosis. However, other exclusions, limitations of coverage, network provider requirements and cost-sharing specified in the plan may still apply.

Will an insurance company be able to question my child’s existing autism diagnosis?

Under the law, the insurance company has the right to review the treatment plan. The law also states that the treatment plan must provide information about the diagnosis. The insurance company will review all medical information including information about the diagnosis so that it can determine the medical necessity of the proposed treatment.

How often can the insurance company require the treatment plan be submitted for review?

Only once every six months, unless both the prescribing physician and the health plan agree to a more frequent treatment plan review cycle.

Can my insurance company deny a claim based on “medical necessity”?

Yes. Like treatment for other conditions, treatment for autism and autism spectrum disorders are subject to determinations of medical necessity. While the insurance company cannot deny coverage because a child has been diagnosed with Autism Spectrum Disorder, an insurance company may deny coverage for a treatment that is determined to not be medically necessary.

Who determines what is medically necessary – the insurance company?

The provider who develops the treatment plan specifies what services they believe are medically necessary and the insurance company reviews that information under their own criteria. Insurance companies use their own medical necessity criteria. The insurance company will provide coverage for what services they determine are medically necessary.

What do I do if a claim or treatment is denied based on “medical necessity”?

If a treatment or claim is denied, be sure to appeal the denial. Missouri law requires that insurance companies have grievance or appeals processes that you can utilize. You can also call DIFP’s Insurance Consumer Hotline for more information on grievance and appeals.

If you are still unsuccessful, you can file a complaint with DIFP. The department cannot make medical determinations; however, we have a process called external review that can resolve adverse determinations regarding covered services.

Who must prescribe or provide my child’s treatment?

For your child’s treatment to be covered by insurance - for all types of autism treatments contemplated under this law - the treatment must be prescribed by a licensed physician, psychiatrist or psychologist – and provided by a physician, psychiatrist, psychologist, behavior analyst or assistant behavior analyst who is licensed or certified in the state of Missouri. If your provider is not licensed or certified in Missouri, meeting the requirements of an “Autism Service Provider” there is no requirement under the law to provide insurance coverage for those treatments.

How can I find out if an “autism service provider” is licensed in the state of Missouri?

The Missouri Division of Professional Registration oversees licensing of autism service providers through the Behavior Analyst Advisory Board. You can check the division’s website to see if your provider is licensed in Missouri.

How can I find out if a provider is in my insurance company’s provider network?

Most insurance companies have provider directories available on their websites. You also can contact your insurance company to ask if a provider is in its network. Remember, information is always subject to change. Insurance companies and providers routinely change who they contract with. You should also periodically check with your provider to make sure it is still in your insurance company’s network.

What if my child’s provider is not in my insurance company’s provider network?

As stated above, insurance companies and providers routinely change who they contract with. Most insurance companies have a number of providers in their networks. If you have trouble finding a provider in your area, you should first call your insurance company for assistance. The law does not require that every provider be in an insurance company provider network and the Department cannot force an insurance company to contract with your provider.

If you use a medical provider that is in your health plan’s network, you will generally pay less out of pocket. Some health plans, like health maintenance organizations (HMOs), may not pay for treatment if you do not use a network provider (and there are other providers available in their network). If you have a provider you want to use, who is not in the insurance company’s network, you can still use that provider – you just may have to pay more out of pocket.

You should call your insurance company ahead of any appointments to verify that the provider is still in network and, if not, to ask what the out-of-network benefits are under your policy or plan so that you can budget for the additional out-of-pocket cost.

My insurance plan says it still will not cover autism treatments or ABA therapy even though this law passed. What can I do?

If you are covered by a health insurance plan that was issued by an insurance company, DIFP may be able to assist you.
We can help you determine whether your health plan is subject to the autism law or exempt.

You can contact us at our Insurance Consumer Hotline, 800-726-7390. You can also file a complaint online.

I live in Missouri but my family and I get our health insurance through my employer, based in another state, and our policy was issued in that state. How does this bill affect our family?

If the health insurance policy is written outside of Missouri but insures Missouri residents, it must comply with the new law.

I have health insurance through my employer but my children are not covered. I would like to buy a separate health insurance policy for my child. Will I be able to get ABA coverage for my child and how much will it cost?

Health insurance policies that are individually underwritten cannot refuse to insure your child or deny coverage because your child has been diagnosed with ASD. These individual policies, when available, are required under the new autism law to make the coverage available, but it is not automatically included, so there will likely be an additional cost associated with that coverage. Ask your insurance agent about this coverage and its cost.

In Missouri, health insurance rates are determined by each insurance company, based upon its expected claims costs. The costs will vary by company and you should shop around. Make sure that you compare not only the cost of this coverage, but the plans’ overall benefits to make sure that you get the best deal possible.

What if my child’s school provides autism services like ABA to my child? Does my health insurance have to reimburse the school?

No. The law states that insurance companies are not required to reimburse or provide coverage for any school-based services.

I am a small employer. I am concerned that my business’s health insurance rates will increase because of this law. What if they do increase - what can I do then?

The law allows the director of DIFP to grant a waiver to a small employer (no more than 50 eligible employees) from the coverage mandate if actual claims over a 12-month period for this coverage result in at least a 2.5 percent increase in health plan premium costs over a calendar year.

I am a mental health provider offering ABA services. How does this bill affect my practice and what do I need to do?

This law establishes the Behavior Analyst Advisory Board within the Division of Professional Registration. The board has established licensure requirements for behavior analysts providing ABA services. The board is now accepting applications for licensure. You can contact the board at 573-526-5804 or online.